Failure to Ensure Resident Dignity During Inappropriate Contact Incident
Penalty
Summary
The facility failed to ensure resident dignity for three cognitively intact residents who were reviewed for dignity concerns. One resident, who requires a wheelchair for mobility and supervision with daily activities, reported that another resident approached her in a common area, rubbed her upper leg, and attempted to touch her perineal area. The incident was witnessed by another resident, who confirmed that the resident in question placed his hand on the inside of the first resident's lower thigh and moved it upwards, prompting the first resident to move away in her wheelchair. The staff member interviewed confirmed the sequence of events and stated that the resident who initiated the contact was sent to the emergency room for evaluation due to his behaviors. The care plan for the resident who was touched did not include any focus area, goal, or interventions related to behaviors of consensual sexual behavior with male peers prior to the incident. Both residents involved were documented as cognitively intact but required constant supervision and resided on a locked psychiatric unit. The facility's policy states that residents have the right to be treated with dignity and respect, but the lack of appropriate care planning and supervision led to a situation where a resident's dignity was not maintained.